1. Skeletal Health in IBD: Screen, then treat (a.k.a. follow the guidelines) Athos Bousvaros MD, MPH Boston Children’s Hospital

2. Disclosures Consulting: Milennium, Dyax, Cubist, Nutricia Research support: Prometheus, Merck With gratitude to Helen Pappa, Francisco Sylvester, and the NASPGHAN Skeletal Health working guideline. JPGN 2011

4. Bone mass is acquired in childhood and adolescence

5. Causes of low bone density in IBD patients Inflammation Low muscle mass Glucocorticoids Delayed puberty Hypovitaminosis D Delayed growth Protein-calorie malnutrition GENETICS

6. How to approach the issue of low bone mineral density in pediatric IBD Ignore it Treat everybody Screen and treat those who need to be treated

7. Which recommendations to follow? THESE – Screen and treat Journal Pediatric GI and Nutrition 2011; 11-25

8. Who to get DEXA on? – Growth failure Height Z score <-2.0 SD BMI <2.0 SD – Primary or secondary amenorrhea – Severe inflammatory disease, esp. hypoalbuminemia – > 6 months of steroid therapy – Clinically significant fractures

9. What kind of DEXA to get Children under 14 years – Total body and spine Children 14 and over – Hip and spine Cost under $150* *healthcarebluebook.com

10. Who and when to get a 25 hydroxy vitamin D level on? Everyone – African American children at higher risk* Once a year, in the winter (cost-$30) If low (<32 ng/ml), treat: – 50,000 units once a week for 10 weeks – Ensure adequate calcium intake during this period *Middleton, JPGN 2013; 57:587

11. Why screen and treat? Not everyone needs to be treated. 60-70% of children with IBD will have a NORMAL BMD Z score Low bone mineral density may change your therapeutic decisions – Additional data in patient decision making – Use steroid sparing agents (e.g. infliximab) – Implement nutritional therapy faster – More rigorous diet/exercise program – Referral to endocrinologist TREATDon’t treat

12. Why screen and treat? Adherence, adherence, adherence!!!! – Approximately 70% of medication doses (ASA and thiopurine) are taken by children – Approximately 25% of adolescents take over 80% of their prescribed ASA doses – Approximately 15% of adolescents take their prescribed thiopurine doses. Calcium and vitamin D = 2-3 extra tabs per day (cost $40/year) Leleiko IBD Journal 2013;19:832

13. Summary: Screen and treat Prevention of osteoporosis is important Not everyone needs to be screened – Focus on the high risk groups Not everyone needs to be treated – Treat those with BMD Z score <-1.0 Treat suboptimal BMD like an extraintestinal manifestation of IBD – Control inflammation, optimize nutrition – Follow up, and monitor adherence